Provider Demographics
NPI:1740245224
Name:DOMINGUEZ, ALISON JEAN (PA)
Entity Type:Individual
Prefix:MS
First Name:ALISON
Middle Name:JEAN
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 36351
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6351
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:704-377-3389
Practice Address - Street 1:1070 VINEHAVEN DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2438
Practice Address - Country:US
Practice Address - Phone:704-783-1840
Practice Address - Fax:704-783-1850
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-01-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC102840363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752609BMedicare PIN